Less invasive surgery for gynecologic tumors

The majority of cancers of the female genital tract are managed primarily by surgery in Western communities. Surgical techniques have developed during the 20th century with a tendency toward increasing radicality in order to deal with those cancers with a propensity for locoregional spread. On occasions during the past 100 years, individual surgeons have made efforts to tailor surgical practice to more appropriately deal with the true risks of spread. In recent times this search for more accurate tailoring has moved on apace and has coincided with the burgeoning interest in minimal access surgical techniques. This review is designed to cover the past year's developments in the quest toward less invasive surgery for gynecologic tumors. A major drawback to tailoring of surgical technique with its inevitable reduction in radicality for some patients is the risk of undertreating the cancer. The temptation for the less experienced or less skilled clinician to reduce radicality because such a move more closely matches his or her level of skill will result in poor results, with the risk that the surgical technique being given a bad name rather than the situation being recognized as a decision to use inappropriate therapy.     

Basic laparoscopic knowledge among gynecologic laparoscopists

OBJECTIVE: Our purpose was to assess the basic knowledge of laparoscopy and laparoscopic sterilization among gynecologic laparoscopists. STUDY DESIGN: A four-part multiple-choice test designed for use in residency training, covering basic aspects of laparoscopy and laparoscopic sterilization, was distributed to 155 registrants at a gynecologic surgery postgraduate course. Test results were compared among subgroups, as well as with results for 23 residents who had taken the test before their rotation in laparoscopic sterilization. RESULTS: Residents scored higher than practitioners on all test segments. No practitioner achieved the 85% correct passing score required of residents. Practitioner scores did not increase as the number of laparoscopic sterilizations performed per year increased, but higher test scores were associated with more recent completion of residency. CONCLUSION: Basic knowledge of laparoscopic sterilization among practicing gynecologists, as measured by a test designed for residents, is less than that of the residents.     

Harmonic scalpel in coronary artery bypass surgery

The startup performance of medical linear accelerators is of increasing importance for modern radiotherapy techniques. The traveling wave-type linear accelerator of the SL series of Philips (now Elekta Oncology Systems) has been modified in its flight tube design to meet this goal of a fast rise time of the radiation field. The new slitless flight tube combined with a redesigned gun servo electronic now achieves start up times of the radiation comparable with those of a standing wave linear accelerator (Siemens Mevatron) according to our measurements.     

Bowel complications in gynecologic laparoscopic surgery and their immediate repair without laparotomy. Four cases

The objective of this study was to develop a method for 3D subtraction CT angiography and to optimize the visualization after semi-automatic segmentation. Ten patients with aneurysms of the abdominal aorta were examined using spiral CT. To reconstruct the vessels, as well as adjacent organs such as the liver and kidneys, one image data volume was acquired before and after injection of the contrast agent. The CT scans were obtained with a Siemens Somatom Plus 4. To improve the results of automatic segmentation, as well as visualization by maximum intensity projection (i.e. removal of bony structures), subtraction of both image volumes is necessary. However, small translation shifts disturb the subtraction process and produce artificial contours. To calculate the disparities along the three coordinate axes of two corresponding image volumes, a cepstrum filter is applied to a pair of image volumes. After detection of the disparities, which manifest as bright spots, the real shift of the two subsignals can be calculated. Translation of the corresponding image volume pairs to their correct positions improves the subtraction process. In all cases the size of the aneurysm and the abdominal organs could be better segmented and visualized. Application of the cepstrum filter and subtraction of the image volumes before and after contrast medium injection completely removes the bony structures in the image data and results in superior visualization results.     

Paraesophageal hernias in elderly patients. An indication for laparoscopic surgery

Paraesophageal hernias are uncommon conditions which appear mainly in elderly people, frequently associated with sliding hernias or gastric volvulus. Considered a high risk pathology, surgical management is preferred to avoid serious complications. Due to advanced age and operative risks, a laparoscopic approach was performed in the three patients with paraesophageal hernia. In mixed hernias, a Nissen or Toupet fundoplication and closure of the hiatal defect was carried out. In a case with gastric rotation, reduction of the herniated stomach and posterior partial fundoplication with gastropexy was performed. No postoperative complications occurred and recovery was satisfactory. Laparoscopic management seems to be a good choice for elective treatment of paraesophageal hernias in elderly patients.     

Incisional hernias after major laparoscopic gynecologic procedures

OBJECTIVE: Our purpose was to determine the incidence of incisional hernias after operative laparoscopy. STUDY DESIGN: A retrospective case review was performed. RESULTS: The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was one in 429 (0.23%) cases and five in 161 (3.1%) cases, respectively; the difference is statistically significant (p = 0.007, Fisher's exact test). Incisional hernias were also significantly more common if the fascia was left open (p = 0.021), although three of the five hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia. CONCLUSION: The underlying fascia should be closed whenever a 10 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites if the trocar is placed through, rather than lateral to, the rectus sheath.     

Witzel gastrostomy in gynecologic surgery

From 1965 to 1990, 46 cases of malignant nasopharyngeal tumours were diagnosed in Iceland. The incidence rate is as low as in other Western countries, 0.6/100,000 per year. Histo-pathological diagnosis were as follows: Undifferentiated carcinoma 45%; squamous cell carcinoma 30%; non-keratinizing carcinoma 7%; and plasmacytoma 9%; lymphoma 7%; rhabdomyosarcoma 2%. Four per cent were diagnosed at stage I, 13% at stage II, 29% at stage III and 54% at stage IV. The overall crude survival at 10 years from diagnosis was 28.3%. The following factors were found to have a prognostic value: Stage of disease, size of tumour (T-classification) and age at diagnosis. Nodal stage (N-classification) alone and sex were not found to be prognostic factors. There was no difference in survival among the different WHO types of cancer. Patients with carcinoma were all treated with radiotherapy. The survival of those who received more than 60 Gy was better than of those who received 60 Gy or less (p = 0.04).     

Application of contact laser scalpel in thoracic surgery

The authors have carried out 296 transthoracic and endoscopic YAG-laser operations in various diseases of bronchopulmonary system. Sapphire and quartz applicator-tips were used as a contact scalpel. The procedures of laser operations with the use of the contact mode are described in detail and comparative evaluation of both types of thermal applicator-tips is given. The combination of cutting and coagulation properties of the contact laser scalpel enables its use in various operations on the lung and pleura including thoracoplastic interventions as well as accomplishment of an endoscopic photoresection of endobronchial tumors.     

Prophylactic ureteral catheterization in gynecologic surgery

OBJECTIVES: To examine the frequency of ureteral catheter usage, its efficacy in preventing injury, and related complications, because the preoperative routine placement of ureteral catheters as a prophylactic measure to prevent ureteral injury is controversial. METHODS: All major gynecologic operations performed between January 1992 and December 1994 were identified. All gynecologic procedures that were preceded by ureteral catheter placement were also identified. A data base maintained by the Department of Quality Management allowed identification of all urinary tract complications and ureteral injuries. Four categories of surgery were analyzed: exploratory laparotomy with catheters, exploratory laparotomy without catheters, operative laparoscopy with catheters, and operative laparoscopy without catheters. The medical records of all patients with urinary tract complications were reviewed. RESULTS: Bilateral prophylactic ureteral catheterization was performed in 469 (15.3%) of 3071 patients. A ureteral injury occurred in 4 (0.13%) of 3071 patients. All four ureteral injuries (0.17%) occurred among 2338 patients who underwent exploratory laparotomy. None of the 733 patients who underwent operative laparoscopy suffered ureteral injury. The incidence of ureteral injury in patients who had ureteral catheters placed before exploratory laparotomy was 2 (0.62%) of 322. Two (0.10%) of 2016 patients who did not have prophylactic ureteral catheters suffered a ureteral injury. There was no statistically significant difference in the incidence of ureteral injury between patients who did and patients who did not undergo ureteral catheterization (P=0.094). CONCLUSIONS: The use of prophylactic ureteral catheters did not affect the rate of ureteral injury in our patients. The very low incidence of ureteral injury among our patients is attributed mainly to meticulous surgical technique.     

An instrument for ultrasonic biometry

A simple instrument has been developed for measurement of axial length and anterior chamber depth. It is pocket sized, and the digital output is easy to interpret. The long term accuracy of 0.2 mm is ideal in helping to eliminate errors of lens selection.     

Prevention of thromboembolic disease in gynecologic surgery

We presented two groups of patients gynecologically operated and examined in a five year period; the first group of 11536 patients was under thromboembolic protection, whereas the second group of 8532 patients was without thromboembolic protection. Protective measures concerning thromboembolic disease were carried out by applying elastic stockings 24 hours before operation and by early post-operative getting up from bed. Low-molecular dextran was applied before operation as well as during the operation in the amount of 500-1000 ml. In risky patients with varicosities, recidive thrombophlebitis and cardiovascular diseases, we applied small doses of heparin subcutaneously two hours before the operation and after the operation every eight hours five days long. With such prevention of thromboembolic disease in gynecologic surgery, we achieved very favorable effects in reducing mortality to 0.05% concerning the operated, while it amounts to 0.3% in those who were without this kind of protection.